This month, Pakistan officially began the quest to vaccinate its 220 million people against COVID-19. To kick-start the country’s mass vaccination program, 500,000 doses of the Sinopharm vaccine arrived from China, Pakistan’s closest ally.
At a launch ceremony on Feb. 2, Prime Minister Imran Khan thanked China for its vaccine largesse and noted the deceptively simple-sounding, yet mammoth, task ahead. “The vaccine will be first administered to health workers treating coronavirus patients, followed by elderly persons in the high-risk age group,” he said.
But multiple challenges lie ahead. Sluggish vaccine supply may fall short of the thresholds needed to achieve sufficient disease control while distribution is likely to be hobbled by the country’s starved public health infrastructure; an inability to target those most at risk; and a checkered history of child and adult vaccination, public suspicion, and vaccine hesitancy. Yet despite this, the pandemic has revealed inherent advantages in Pakistan that might fortuitously blunt the full impact of these failures.
Pakistan’s pandemic narrative began to be scripted in February 2020. Though inbound travelers from China were initially seen as the obvious threat, early cases were determined to be from pilgrims who had returned to the country after visiting various shrines in Iran. When efforts were belatedly deployed to clamp down on the Taftan border crossing with Iran, around 8,000 pilgrims had already made their way back home to different cities in Pakistan. By then, an unforgiving and unchecked COVID-19 had hit the nation’s cities.
But despite its dense population, a dilapidated public health and medical infrastructure, and a national lockdown imposed on April 1 that was lifted on May 9 despite the post-Ramadan COVID-19 surge to come, Pakistan was able to stave off the worst of its first pandemic wave. This can be largely attributed to the civilian government’s necessary partnership with the military—the most powerful force in the country—for logistics, coordination, and implementation of a national response combined with a youthful population, culturally limited social networks that do not extend beyond immediate family members, and potentially—though speculatively—to preexisting immunity from exposure to other strains of the coronavirus.
By September 2020, daily infections had plummeted by more than 90 percent from their peak levels on June 14. The daily death toll was largely in single digits, and test positivity was well below the World Health Organization’s (WHO) recommended threshold of 5 percent, indicating adequate disease control. Though these numbers have sometimes been discounted due to concerns about undercounting and underreporting, they are supported by hospital and graveyard data.
A milder first wave meant that Pakistanis were relatively unafraid of the virus. And although public suspicion, indifference, and poor enforcement of public health measures inevitably spawned a second wave in November 2020, the numbers have since trended down.
“We did have periods where there were no beds, but it was not as bad as the first wave,” said Faisal Mahmood, head of infectious diseases at Aga Khan University Hospital in Karachi. “Also this wave was flatter than the last, putting less pressure on the system overall.”
That second wave metrics—case positivity, daily cases, and daily death toll—have declined in the absence of a major lockdown policy or a change in public behavior is notable. That this decrease occurred even before a single protective needle was jabbed into a Pakistani arm is encouraging. But the signs for the vaccine rollout are less promising, and the country may falter at the final hurdle.
Of Pakistan’s 220 million inhabitants, experts say that there are roughly 100 million adults who are eligible to receive the vaccine at this time. In preparation for its rollout, Pakistan has already approved an array of vaccines for emergency use, most notably AstraZeneca, China’s Sinopharm, and Russia’s Sputnik V.
As of now, the shots will primarily be procured through COVID-19 Vaccines Global Access (COVAX), an initiative helmed by the WHO and the United Nations-backed vaccine alliance Gavi, and the government’s $250 million budget allocation for vaccines. Despite concerns about creating access inequalities, the government has also permitted the private sector to import vaccines and inoculate those willing to pay. Provincial governments have also been given the green light to place vaccine orders independently.
COVAX was hatched to provide poorer nations like Pakistan equitable access to COVID-19 vaccines. Because vaccines are provided in proportion to population size, Pakistan is expected to receive enough doses to cover 45 million people by the end of 2021. But the COVAX vaccine spigot remains impeded by critical questions about supply and timing. Around 17 million doses of the AstraZeneca vaccine have already been secured through COVAX and are expected to arrive in the coming weeks to months. Based on the government’s budget, another 20 to 30 million people may be able to roll up their sleeves.
Decisions on specific vaccines will remain fluid as new efficacy and resistance data flows in daily. And over time, younger age groups may also become eligible for shots. Based on currently available data, Pakistan has not approved the Sinopharm formulation for those over the age of 60.
“Pakistan’s vaccine response right now is the vaccine response of beggar countries. The headline is ‘China is donating 500,000 vaccine doses to Pakistan.’ They are putting out with all kinds of pride that they are getting hand-me-downs from Gavi or free AstraZeneca vaccine,” said Zulfiqar Bhutta, founding director of the Institute for Global Health & Development at Aga Khan University.
Pakistan has little chance of getting enough doses to vaccinate its entire adult population this year. Although there is no indigenous vaccine, the country is further hamstrung by its inability to manufacture vaccines domestically on any scale let alone that of their behemoth next-door neighbor, the Serum Institute of India.
But if Pakistan’s limited vaccine supply is administered judiciously, none of this may be fatal. A sizable dent in morbidity and mortality is still possible. According to Bhutta, the focus should be on front-line workers, the elderly, and those with comorbidities, making up 40 to 50 million people total. “You do that, and you spare yourself the consequences of severe COVID hospitalizations and death,” he said.
If vaccines trickle in over the second and third quarters of this year and the most vulnerable people are protected, the outlook is still hopeful. Even if infected, the country’s disproportionately young population is unlikely to place great strain on hospitals or medical resources. Further, antibody studies being conducted at the population level already reveal at least 30 to 40 percent COVID-19 exposure in areas.
But even with vaccines in hand, Pakistan’s greatest barrier is likely to be distribution. Far more resourceful nations are already struggling to immunize their populations—and Pakistan faces additional challenges because it lacks any blueprint for adult vaccination. Apart from the tetanus toxoid vaccine given to pregnant mothers, there is no routine adult vaccination scheme in the country. As Saad B. Omer, director of the Yale Institute for Global Health, said, “There is very little muscle memory of folks doing this kind of stuff for an adult population.”
Even Pakistan’s dedicated pediatric vaccination efforts have struggled. Despite the Expanded Programme on Immunization (EPI) that inoculates children against multiple vaccine-preventable infections, under-age-5 deaths account for nearly half of all deaths in the country. And though significant inroads have been made against polio, Pakistan has been unable to eradicate it. The difficulties are compounded by Pakistan’s rugged terrain in the north and south.
The success of Pakistan’s phased national vaccination campaign will depend on targeting high-risk individuals who require immunization and then ensuring they have access to a free vaccine. Equally crucial will be public understanding of the vaccine’s safety and how mass vaccination can end the pandemic.
Pakistan has opted for a novel approach that exclusively uses digital communication to register and schedule its citizens for the vaccine at adult vaccination centers in the country. In these nascent days of the vaccine program, it is entirely unknown whether this can reach an elderly population that may not be technologically literate or may lack access to a phone altogether.
“There is requisite experience, but this is slightly different in the sense that it is digital. Reaching out to front-line health care workers, which we are doing right now, is also a good test for the system. So the learnings learnt and the shortfalls during this period will be fed into the next phase, which is older individuals,” said Assad Hafeez, former director-general of health at the Ministry of National Health Services, Regulation, and Coordination.
In conjunction with provincial governments, COVID-19 adult vaccination centers have been incorporated into existing health infrastructure. But officials say no resources or immunization workers have been siphoned off from other ongoing vaccination programs like typhoid for those under the age of 15, polio, or other EPI efforts, which alone are responsible for about 97 percent of total immunizations in Pakistan.
Even though the private sector will inevitably dispense vaccines, concerns will also linger about the country’s elite and privileged jostling their way to the front of the line for the free, government-purchased vaccines. According to Hafeez, security arrangements “from point of entry to storage to distribution to inoculation sites” will be the responsibility of local law enforcement agencies. In addition, the National Institute of Management will register and track all vaccines electronically to guarantee their delivery to rightful recipients.
But though these factors may slow the rollout of the vaccine and affect some of its success, nothing threatens to scupper Pakistan’s efforts more than vaccine hesitancy and suspicion.
Highly visible politicians have been poor public health role models. Their large political rallies and inconsistent masking evince apathy at best and COVID-19 denial at worst.
A recent Gallup Pakistan poll showed 49 percent of Pakistanis don’t want to get vaccinated. Of the 46 percent who acquiesced to a vaccine, only 4 percent desired a Western-made one. Even more troubling was another Gallup Pakistan survey done in October 2020. It found that 55 percent of Pakistanis did not believe in the coronavirus while 46 percent felt it was a conspiracy.
These sentiments were not voiced in a vacuum. The opinions and fears of many Pakistanis are expressed against a backdrop of fatal militant attacks on polio vaccinators and the CIA’s use of a hepatitis B vaccination program to gather intelligence in Abbottabad for the raid on Osama bin Laden. There is also a hodgepodge of conspiratorial concerns about vaccine side effects, animal DNA, microchips, and nanoparticles.
As historians Jeremy Greene and Dora Vargha wrote, vaccines are “technologies of trust” with success dependent on “maintaining confidence in national and international structures through which vaccines are delivered.”
But although the lies and misinformation must be acknowledged, it isn’t feasible or even prudent to address them all individually. “The idea is to build trust,” Omer said. “It’s fraught with challenges and pitfalls if you try and answer every last myth. But focusing on genuine trust is important. Using people who already have a cachet of trust as community validators, as folks who turn the gaze of the community toward science. That is likely to be more helpful rather than trying to correct every myth.”
Enlisting doctors, respected clerics, celebrities, and influencers, especially those previously diagnosed with COVID-19, for public messaging on vaccination can make campaigns credible and relatable.
Ali Gul Pir, a comedian with a large following, has been doing vaccine and COVID-19 advocacy work through various mediums since the pandemic began in Pakistan. “We came across this clip of a person who actually filed a petition in the court that vaccines should not be allowed in Pakistan,” he said. “We thought it would be the best way to highlight that absurdity and tackle that with humor. I find when you put a serious message in a humorous way, it really is digested and absorbed easily by the audience.”
Pakistan has been careening toward disaster at numerous points during the pandemic. Yet despite the limits of the country’s public health and medical systems, it has largely escaped the worst of both waves. These past successes should not breed complacency about COVID-19 vaccination—an especially thorny undertaking for a nation that has not inoculated its adult population before. To protect its most vulnerable people, Pakistan must now fully grapple with its previously insuperable vaccine barriers.
